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<form action="${domain}/admin/sixth/d" method="post">
    <div align="center" width="1000px">
        <td><input name="oName" type="hidden" value="${oName}"></td>

        <h4>表5 2016年免疫规划内的免费疫苗情况调查表</h4>

        <table border="1" cellspacing="0" cellpadding="0">
            <tr>
                <td >疫苗名称</td>
                <td>接种人次数</td>
            </tr>

            <tr>
                <td><input readonly unselectable="on" name=sixthD[0] value="乙肝疫苗" type="hidden">乙肝疫苗</td>
                <td><input name="sixthD[1]" type="number" step="0.01"></input></td>
            </tr>

            <tr>
                <td><input readonly unselectable="on" name=sixthD[2] value="脊髓灰质炎疫苗" type="hidden">脊髓灰质炎疫苗</td>
                <td><input name="sixthD[3]" type="number" step="0.01"></input></td>
            </tr>

            <tr>
                <td><input readonly unselectable="on" name=sixthD[4] value="卡介苗" type="hidden">卡介苗</td>
                <td><input name="sixthD[5]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[6] value="百白破" type="hidden">百白破</td>
                <td><input name="sixthD[7]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[8] value="麻风疫苗（麻疹疫苗）" type="hidden">麻风疫苗（麻疹疫苗）</td>
                <td><input name="sixthD[9]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[10] value="麻腮风疫苗（麻腮疫苗、麻疹疫苗）" type="hidden">麻腮风疫苗（麻腮疫苗、麻疹疫苗）</td>
                <td><input name="sixthD[11]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[12] value="乙脑减毒活疫苗" type="hidden">乙脑减毒活疫苗</td>
                <td><input name="sixthD[13]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[14] value="A群流脑疫苗" type="hidden">A群流脑疫苗</td>
                <td><input name="sixthD[15]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[16] value="A+C流脑疫苗" type="hidden">A+C流脑疫苗</td>
                <td><input name="sixthD[17]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[18] value="甲肝减毒活疫苗" type="hidden">甲肝减毒活疫苗</td>
                <td><input name="sixthD[19]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[20] value="出血热疫苗（双价）" type="hidden">出血热疫苗（双价）</td>
                <td><input name="sixthD[21]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[22] value="炭疽疫苗" type="hidden">炭疽疫苗</td>
                <td><input name="sixthD[23]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[24] value="钩体疫苗" type="hidden">钩体疫苗</td>
                <td><input name="sixthD[25]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[26] value="乙脑灭活疫苗" type="hidden">乙脑灭活疫苗</td>
                <td><input name="sixthD[27]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=sixthD[28] value="甲肝灭活疫苗" type="hidden">甲肝灭活疫苗</td>
                <td><input name="sixthD[29]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=sixthD[30] ></td>
                <td><input name="sixthD[31]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=sixthD[32] ></td>
                <td><input name="sixthD[33]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=sixthD[34] ></td>
                <td><input name="sixthD[35]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=sixthD[36] ></td>
                <td><input name="sixthD[37]" type="number" step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=sixthD[38] ></td>
                <td><input name="sixthD[39]" type="number" step="0.01"></input></td>
            </tr>


        </table>
        <p align="left">
            注：</br>
            1、接种人次数需要填写的是在本机构接种免疫规划内免费疫苗的人次数。</br>
            2、如本机构无某一疫苗的接种，请在对应的单元格中填横线。</br>
            3、表中没有列出的疫苗，请在空行中补充。</br>
              </p>


    <button type="submit" ><b>提交并进入下一表格</b></button>

    </div>

</form>
</body>
</html>